chapter 67
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? 2:30 p.m. 4:00 p.m. 3:00 p.m. 5:30 p.m.
4:00 pm Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? Every 30 minutes Every 45 minutes Every 15 minutes Every hour
Every 15 minutes
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action? Comprehend spoken words Speak at all Form understandable words and comprehend spoken words Form understandable words
Form understandable words and comprehend spoken words Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to communicate effectively with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Systolic blood pressure less than or equal to 185 mm Hg Intracranial hemorrhage Age 18 years or older Ischemic stroke
Intracranial hemorrhage Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? Transient ischemic attack (TIA) Right-sided cerebrovascular accident (CVA) Completed Stroke Left-sided cerebrovascular accident (CVA)
Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? Noncontrast computed tomogram 12-lead electrocardiogram Carotid ultrasound study Transcranial Doppler flow study
Noncontrast computed tomogram The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? Semi-Fowler's Prone High-Fowler's Supine
Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply. Vomiting Sudden, severe headache Seizures Loss of balance Numbness or weakness of an extremity Altered level of consciousness
Vomiting Sudden, severe headache Seizures These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.
A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? atherosclerotic plaque diplopia bruit TIA
bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? Avoiding the use of hand gestures Speaking loudly Speaking in complete sentences Establishing eye contact
Establishing eye contact The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? physical therapist spouse chaplain home care nurse
spouse The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? Decreased level of consciousness (LOC) Elevated blood pressure Increased urine output Decreased heart rate
Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified? Hypertension Atrial fibrillation Advanced age Obesity
Advanced age Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Nonmodifiable risk factors include advanced age, gender, and race.
The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? Maintain hydration by drinking eight glasses of fluid a day. Apply warm or cool cloths to the forehead or back of the neck. Perform the Heimlich maneuver. Use pressure-relieving pads or a similar type of mattress.
Apply warm or cool cloths to the forehead or back of the neck. Warmth promotes vasodilation; cool stimuli reduce blood flow.
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? Hypertension Increased intracranial pressure (ICP) Bleeding Headache
Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.
From which direction should a nurse approach a client who is blind in the right eye? From the left side of the client From the right side of the client From directly in front of the client From directly behind the client
From the left side of the client The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Temporal Frontal Occipital Parietal
Frontal If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Nausea, vomiting, and profuse sweating Hemiplegia, seizures, and decreased level of consciousness Tachycardia, tachypnea, and hypotension Difficulty breathing or swallowing
Hemiplegia, seizures, and decreased level of consciousness spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.ss
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? Surgery 6 weeks ago Taking digoxin International normalized ratio greater than 2 Two hour time period of the stroke
International normalized ratio greater than 2 The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client? Take medication only during the morning when it's calm and quiet. Take medication just before going to bed at night. Take medication as soon as symptoms of the migraine begin. Take medication only when migraine is intense.
Take medication as soon as symptoms of the migraine begin. The nurse reinforces the drug therapy regimen and instructs the client on self-administration of medications. To stop the migraine headache, the nurse stresses the importance of taking medication as soon as symptoms of the migraine begin and not when the migraine intensifies. The client needs to be instructed to take medications before going to bed or in the morning.
Which of the following is the chief cause of intracerebral hemorrhage (ICH)? Uncontrolled hypertension Hypercholesterolemia Migraine headaches Diabetes
Uncontrolled hypertension Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension. Diabetes, hypercholesterolemia, and migraine headaches are not a chief cause of ICH.
A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education? When symptoms cease, the client will return to presymptomatic state. A TIA is an insidious, often chronic episode of neurologic impairment. Symptoms of a TIA may linger for up to a week. Two thirds of people that experience a TIA will go on to develop a stroke.
When symptoms cease, the client will return to presymptomatic state. Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? Monthly prothrombin levels Carotid endarterectomy Anticoagulant therapy Cholesterol-lowering drugs
Anticoagulant therapy Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if indicated to manage atherosclerosis. Prothrombin and international normalized ratio (INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque.
A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Stent placement Removal of the carotid artery Percutaneous transluminal coronary artery angioplasty Carotid endarterectomy
Carotid endarterectomy If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Large artery thrombosis Cerebral aneurysm Cardiogenic emboli Small artery thrombosis
Cerebral aneurysm
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? Elevating the head of the bed to 30 degrees Monitoring for seizure activity Maintaining a patent airway Administering a stool softener
Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.
The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including eating fish no more than once a month. a high-protein diet and increased weight-bearing exercise. a low-fat, low-cholesterol diet and increased exercise. a low-cholesterol, low-protein diet and decreased aerobic exercise.
a low-fat, low-cholesterol diet and increased exercise. Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including a low-fat, low-cholesterol diet and increased exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.
